Technology-enhanced simulation-based learning in orthodontic education: A scoping review

ABSTRACT Introduction: Technology-enhanced simulations seem to be effective in dentistry, as they can support dental students to improve competencies in simulated environments. However, implementation of this technology in orthodontic education has not been reviewed. Objective: This scoping review aimed to comprehensively summarize the use of technology-enhanced simulations in orthodontic practice. Methods: A systematic search was conducted to identify literature on technology-enhanced simulation-based learning in orthodontic education published from 2000 to 2021. The search was conducted up to September 2021 to identify articles from Scopus, Embase, PubMed, ProQuest Dissertations & Theses Global, Google Scholar and the reference lists of identified articles. Results: The search identified 177 articles. Following the inclusion and exclusion criteria, 16 articles of 14 digital simulators were included in this review. The findings demonstrated an increasing use of technology-enhanced simulations in orthodontic education. They were designed in several formats, including three-dimensional virtual format, augmented reality, virtual reality, automaton, haptic, and scenario-based simulations. These simulations were implemented in varied areas of orthodontics including diagnosis and treatment planning, bracket positioning, orthodontic procedures, facial landmark, removable appliance and cephalometric tracing. Most included articles demonstrated the development process without outcome evaluation. Six studies provided outcome evaluations at reaction or learning levels. None of them provide the evaluation at behaviour and results levels. Conclusion: Insufficient evidence has been generated to demonstrate the effectiveness of technology-enhanced simulations in orthodontic education. However, high-fidelity computer-based simulations together with robust design research should be required to confirm educational impact in orthodontic education.


INTRODUCTION
The COVID-19 pandemic has widely impacted a variety of areas, including the educational field. In this context, emphasis on hybrid learning (presential/distance) is unavoidable to minimize the risk of infection. The concerns of physical distancing have been raised in healthcare education, including orthodontic practice.
Unlike other educational areas, the emphasis of orthodontic education is to improve psychomotor skills, in addition to cognitive and affective domains. 1 Technology-enhanced simulation-based learning can be designed in varied formats, such as digital simulators, augmented reality (AR), virtual reality (VR) and serious games, to enhance knowledge and skills in dental practice. [2][3][4] All of these options should be considered for orthodontic training.
Orthodontic practice requires knowledge and skills in various areas, such as anatomy of head and neck, growth and development, physiology and biomechanics of tooth movement. 5,6 Furthermore, the learning outcomes of orthodontic programs generally require varied psychomotor skills, such as wire bending, bracket positioning, and tooth stripping for interproximal reduction. 6 Residents are also required to be competent in the affective domain, to communicate with patients and their guardians or to deal with orthodontics-related psychological concerns among patients. 7 Therefore, learning and practice in laboratories followed by clinical settings should be necessarily designed for all orthodontic postgraduate programs.
Sipiyaruk K, Kaewsirirat P, Santiwong P -Technology-enhanced simulation-based learning in orthodontic education: A scoping review The COVID-19 outbreak seems to have negative impact on orthodontic practice, evidenced by a delay of orthodontic treatment caused by the lockdown or quarantine. 8,9 There is evidence demonstrating a decrease in the number of new-patient visits during the pandemic. 10 Patients may feel unsafe or experience restrictions to attend the orthodontic appointments. 11,12 They may also have financial problems related to the pandemic. 12 A survey in 69 dental schools found a restriction of clinical practice during the pandemic, as only urgent or emergency services were permitted. 13 This situation seems to be a major challenge for orthodontic education, where training in clinical settings is highly required. 14 The consideration of appropriate substitutes to clinical practice should be required to ensure that graduates will be able to achieve the expected learning goals.
Unlike a cognitive domain, which can be replaced by an online format or a hybrid learning model, orthodontic practice requires clinical techniques learning, where technology-enhanced simulation-based learning can play an important role to offer substitutes or supplements to clinical practice. There is evidence reporting that digital simulators can enhance psychomotor skills, preparing dental undergraduates for practice in clinical settings. 15,16 These technology-enhanced simulations can be applied in various fields of dental education, including prosthodontics, endodontics, maxillofacial surgery, periodontology, radiology, pediatric dentistry and orthodontics. 17 Sipiyaruk K, Kaewsirirat P, Santiwong P -Technology-enhanced simulation-based learning in orthodontic education: A scoping review Despite the high setup costs and trained staff required, technology-enhanced simulators can be considered more effective than traditional simulations, in terms of unlimited training sessions with objective and repetitive feedback, 2 resulting in higher efficiency of teaching and learning in dental education.
Although technology-enhanced simulation-based learning has been used to assist dental education, no review of its implementation into clinical training of orthodontic practice could be found. Consequently, this scoping review was conducted to comprehensively analyze empirical studies of the use of technology-enhanced simulation-based learning in orthodontic practice.
The knowledge and understanding retrieved from this review would be supportive for dental educators to systematically and comprehensively consider the design and implementation of technology-enhanced simulations to provide optimum settings for teaching and training in orthodontic education.

REVIEW DESIGN
A scoping review of the literature was considered as the most appropriate method to synthesize the use of technology-enhanced simulation-based learning. The purposes of this type of review are to identify key concepts, characteristics, available evidence and research gaps of an interesting topic. 18 This design is also appropriate for a complex issue, especially when it has not been yet comprehensively reviewed. 19 The review process comprises six stages, as follows: 1) identify research questions or purposes, 2) identify relevant literature through systematic searches, 3) select articles in accordance with inclusion and exclusion criteria, 4) analyze the data retrieved from the identified evidence, 5) collate, summarize, and report results; and 6) consult external stakeholders for further suggestions or insights to the review (optional). 20 This report follows the PRISMAS checklist for scoping reviews. 21

RESEARCH QUESTIONS
This scoping review sought to answer the following questions: » What was the trend in the current use of technology-enhanced simulation-based learning in orthodontic education?
» What types of technology-enhanced simulation-based learning were made available to orthodontic education? covering as many as available publications. As several articles identified from the initial search were technical reports demonstrating only the development process of simulations, the terms 'training', 'education', 'learning', and 'teaching' were considered for 'Outcome', rather than 'Knowledge', 'Skill', and 'Competency'. Moreover, the search terms for 'Outcome' were still required to enhance the emphasis on the use of technology-enhanced simulation on educational purposes, rather than its use as a process of orthodontic treatment. The search process was iteratively performed and adjusted to ensure its robustness before conducting the final search. 23 The last search was conducted on September 30, 2021.

INCLUSION AND EXCLUSION CRITERIA
All types of empirical studies of technology-enhanced simulation-based learning in orthodontic education published from Sipiyaruk K, Kaewsirirat P, Santiwong P -Technology-enhanced simulation-based learning in orthodontic education: A scoping review January 2000 to September 2021 were included in this review.
Grey literature was also expected to cover technology-enhanced simulation in orthodontic education wherever possible; however, the references were excluded if fail to include technology-enhanced simulations or were not used for teaching or training orthodontic professionals or residents. They were also not included if not available in full-text.

STUDY SELECTION AND DATA EXTRACTION
All identified articles were screened by two researchers (KS and PK) to consider whether or not they were eligible for this review.  Table 1). The data from included articles were extracted by a researcher experienced with systematic reviews (KS). The data extraction was then reviewed by another researcher (PS) to confirm the validity. Disagreement was settled by discussion among researchers (KS, PK, and PS) to achieve a consensus. Removable orthodontic appliance, called AR-Demonstrator-App Augmented reality that allows users to learn manufacturing steps of removable orthodontic appliance on a plaster model To explore student perceptions on handling, acceptance, and usefulness of the intervention use The survey using a paper-based questionnaire demonstrated the students tended to have positive attitudes toward the intervention Technical report without a data collection process and evidence of educational outcomes Table 1: (continuation) Information extracted from the included articles.
Sipiyaruk K, Kaewsirirat P, Santiwong P -Technology-enhanced simulation-based learning in orthodontic education: A scoping review

LITERATURE IDENTIFIED FROM THE SEARCH
The search conducted across the four databases identified 170 articles. Google Scholar and the reference lists of identified articles were also screened, and seven papers were further identified. After that, 33 duplicates were removed and 144 titles and abstracts were reviewed. One hundred and eight articles were excluded, as they were reviews and/or not relevant to technology-enhanced simulations. Thirty-six full-texts were then assessed, and twenty articles were excluded: ten were technology-enhanced simulations used for only orthodontic treatment, rather than for training purposes; three were interventions that were not considered as technology-enhanced simulations; three were not related to orthodontics; two were reviews; one was a traditional simulation; and one was not available in full-text.
The article selection process is presented in Figure 1.

CHARACTERISTICS OF INCLUDED ARTICLES
The sixteen articles included in this scoping review comprised nine journal articles, 24-32 six conference papers, [33][34][35][36][37][38] and one PhD thesis. 39 Two articles were experimental designs comparing intervention and conventional approaches, 27,30 and one of them was a randomized control trial. 27 Two studies used only a questionnaire survey design to gather user perception toward the use of technology-enhanced simulations. 25,28 Two articles Moreover, five articles had already been made available within the 10-month period in 2021. [28][29][30][31][32]

INCLUDED IN THIS REVIEW
Two experimental studies demonstrated cognitive improvement of participants in orthodontic diagnostics and treatment planning after interacting with the simulations. 27,30 In addition, orthodontic residents and orthodontists tended to have positive perceptions toward the use of simulations. 25,28,29,31 They believed that they could gain confidence in orthodontic treatment procedures with the simulation. 25 Participants were also likely to report high acceptance of the simulation in improving diagnostic competence. 29 There were eight simulations, reported in ten publications, which were designed for the improvement of cognitive domain in orthodontic practice. 24 level. 25,28,29,31 Ten articles were published without reporting the outcome evaluation in terms of orthodontic education. 24,26,[32][33][34][35][36][37][38][39] None of the articles performed the evaluation of learning outcomes at behaviour and results levels. Several key strengths of technology-enhanced simulations should be considered. Firstly, they allow users to perform required tasks repetitively until the expected outcomes are achieved. 42,43 In addition, with immediate feedback, those simulations can also support users to conduct self-directed learning, and therefore the needs of one-to-one support from dental instructors can be reduced. 44  When considering the Kirkpatrick model, 40 the common types of the outcome evaluation of the articles included in this scoping review appeared to be similar to research in other areas of dental education, which were reaction and learning levels. 15,41 There seemed to be no research evaluating the outcome at behaviour and results levels that could be considered as significant impact of the simulation development. In addition, while

DISCUSSION
Bloom's affective domain should be required for orthodontic practice, none of the included articles discussed the enhancement of this competence, although simulation-based pedagogical approaches can be considered as effective in improving these skills. 49 Consequently, further design and development of high-fidelity computer-based simulations are necessary to simulate actual patient tasks, as well as research with robust design (e.g. well-blinded randomized controlled trials) to confirm these outcome evaluation in orthodontic education.